Form - Final RSTMCH

CANCER RELIEF SOCIETY’S
RST REGIONAL CANCER HOSPITAL & TEACHING INSTITUTE,

MANEWADA ROAD, NAGPUR-27.
Price Rs. 100/-
CANCER RELIEF SOCIETY

RASHTRA SANT TUKDOJI REGIONAL CANCER HOSPITAL
AND TEACHING INSTITUTE
AND RESEARCH INSTITUTE
Manewada Road, Nagpur - 440 027. (M.S.)
Ph. No. (0712) 2748995, FAX No. (0712) 2754546
Approved by:- Govt. of Maharashtra PTI / 2002 / (306 / 02) / TE-2
Dated 7th October, 2002 & Affiliated to MSBTE Mumbai.
Application
No.
____________________________________________________________________
APPLICATION FOR FIRST YEAR ADMISSION TO THE POST GRADUATE DIPLOMA
COURSE IN - 1] RADIOTHERAPY TECHNOLOGY
2] MEDICAL LABORATORY TECHNOLOGY
NOTE: 1) Please fill application in full and correctly.

Please strike out at the asterist Mark * the unnecessary
2) works.
3) Please submit the application to the appropriate officer only.
For Office use only

.
Application for admission to :- PGDRTT / PGDMLT
Category (Cast) :- Open / Reserved ________________________

(Write specific category) PHOTO
Claim against any other category PH / Defence / NRI / ___________
Marks obtd in qualifying

Exam.: Name of Student
Out of ______________
H.S.C. B.Sc. ______________
Domicile of Candidate :- MAH / OMS
Year of passing qualifying exam. ____________________

Merit no, in provisional list : ____________________
Admitted in
Roll No. allotted in admitted merit list :____________________ _______________
_________________ _________________
(Signature of Scrutinizer) (Signature of Principal)
To,
The Director,
RST Regional Cancer Hospital
& Teaching Institute & Research Institute,
( Cancer Relief Society )
Manewada Road, Nagpur - 440 027. ( M.S.)
I request you to kindly consider my candidature for admission to the following

1 Post Graduate Diploma Course in Radiotherapy Technology
2 Post Graduate Diploma in Medical Laboratory Technology
at the Institute under your authority, I am submitting herewith all the necessary details.
1 Surname
2 First Name
3 Father's Name
4 Whether Male or Female M F

MM / DD / YYYY
5 Date of birth
6 Whether Maharashtrian Yes No
7 If NOT, the name of the State or Union

territory of domicile.
8 Mother tongue
9 Whether Indian National Yes No
10 Permanent Address
Pin Code
11 District
12 Taluka
13 State
14 Whether Place of Residence is R U

Rural of Urban
15 Name of guardian
16 Relationship with the guardian
17 Profession of the guardian
18 Gross annual income of the

guardian Rs.
19 Whether guardian is an employees

of Govt. of India or Govt. of India YES NO
undertaking
20 If, Yes, the month and year of his

transfer to Maharashtra
21 Whether his transfer was done YES NO

elsewhere out of Maharashtra
22 Address for correspondence

23 District
24 Taluka
25 State
26 The name of B.Sc. Or equivalent

examination
27 Name of University
28 Month & year of passing the

above examination
29 Whether B.Sc. Examination is YES NO
passed in one and the same
attempt
30 No. of attempts made to pass the

examination
31 The places of learning in previous three years :

Year Class Name and Address of College
200
200
200
32 Marks * obtained in B.Sc. Examination:

Subject Mark Out of
Grand Total
Mathematics
Physics
Chemistry / Electronics
English
33 Total marks obtained in B.Sc.

Examination or its equivalent.
34 * YES NO
Whether belonging to Scheduled Caste
Scheduled Tribe * YES NO

Denotified Tribe * YES NO
Nomadic Tribe * YES NO
Other Backward Class * YES NO
Special Backward Class * YES NO
35 Name of the Caste
36 Whether belonging to minority * YES NO

community
37 * If yes, the name of the same
38 The name of the religion
39 Whether passed the B.Sc. Final * YES NO

examination
40 Whether physically handicapped * YES NO
41 Whether spouse, son, daughter of a * YES NO

defence service person
42 Whether project affected person. * YES NO
MEDICAL FITNESS CERTIFICATE

( By Registered Medical Practitioner )
I have thoroughly examined *Shri / u________________________________________ today the

______________ day of ________________ 200____ and therefore certify that *he / she sound infirmity,
no disease, no serious defects in eye sight, no physical disability and no mental infirmity. I further certify
that *he / she is fit to undergo instructions in hospital and he / she has nothing that can unfit * him / her now
or in future to undergo manual work in laboratories, classrooms, hospitals drug stores, radiotherapy
application or any outdoor service as a Medical Laboratory / Radiotherapy Technologist.
Date: __________________ Signature________________
Address: ____________________________ Name ____________________

____________________________________ Qualifications ________________
____________________________________ Registration No._______________
SEAL
SCRUTINY FORM
Sr. No. COPIES OF CERTIFICATES REMARKS FOR SCRUTINY
1 Domicile Certificate for other State applications NA / Yes / No
2 SSC Certificate Yes / No
3 Mark Sheet of SSC Examination Yes / No
4 Attempt Certificate NA / Yes / No
5 Leaving Certificate of the last attended College Yes / No
6 B.Sc. Mark Sheet Yes / No
7 Caste Certificate for OBC / DT / NT / SBC NA / Yes / No
8 Caste Certificate for SC / ST NA / Yes / No
9 Medical fitness Certificate for physically handicapped NA / Yes / No
10 Medical fitness Certificate for Applicant Yes / No
Transfer Certificate in case of employee of Govt. of India or Govt.

11 NA / Yes / No
of India Undertaking
12 Defence Certificate NA / Yes / No
13 Creamy layer for NT2, NT3, and OBC Yes / No
Place : _________________Signature: _____________________________________________
Date : _________________Name of Scrutinizer :____________________________________

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CANCER RELIEF SOCIETY’S

RST REGIONAL CANCER HOSPITAL & TEACHING INSTITUTE,

Price Rs. 100/-

CANCER RELIEF SOCIETY

NOTE: 1) Please fill application in full and correctly.

For Office use only

Category (Cast) :- Open / Reserved ________________________

Claim against any other category PH / Defence / NRI / ___________

Marks obtd in qualifying

Domicile of Candidate :- MAH / OMS

Year of passing qualifying exam. ____________________

I request you to kindly consider my candidature for admission to the following

4 Whether Male or Female M F

6 Whether Maharashtrian Yes No

7 If NOT, the name of the State or Union

9 Whether Indian National Yes No

14 Whether Place of Residence is R U

16 Relationship with the guardian

17 Profession of the guardian

18 Gross annual income of the

19 Whether guardian is an employees

20 If, Yes, the month and year of his

21 Whether his transfer was done YES NO

22 Address for correspondence

26 The name of B.Sc. Or equivalent

28 Month & year of passing the

30 No. of attempts made to pass the

31 The places of learning in previous three years :

32 Marks * obtained in B.Sc. Examination:

33 Total marks obtained in B.Sc.

Scheduled Tribe * YES NO

Nomadic Tribe * YES NO

Other Backward Class * YES NO

Special Backward Class * YES NO

35 Name of the Caste

36 Whether belonging to minority * YES NO

37 * If yes, the name of the same

38 The name of the religion

39 Whether passed the B.Sc. Final * YES NO

40 Whether physically handicapped * YES NO

41 Whether spouse, son, daughter of a * YES NO

42 Whether project affected person. * YES NO

MEDICAL FITNESS CERTIFICATE

I have thoroughly examined *Shri / u________________________________________ today the

Date: __________________ Signature________________

Address: ____________________________ Name ____________________

____________________________________ Registration No._______________

Sr. No. COPIES OF CERTIFICATES REMARKS FOR SCRUTINY

1 Domicile Certificate for other State applications NA / Yes / No

2 SSC Certificate Yes / No

3 Mark Sheet of SSC Examination Yes / No

4 Attempt Certificate NA / Yes / No

5 Leaving Certificate of the last attended College Yes / No

6 B.Sc. Mark Sheet Yes / No

7 Caste Certificate for OBC / DT / NT / SBC NA / Yes / No

8 Caste Certificate for SC / ST NA / Yes / No

9 Medical fitness Certificate for physically handicapped NA / Yes / No

10 Medical fitness Certificate for Applicant Yes / No

Transfer Certificate in case of employee of Govt. of India or Govt.

Date: __ Signature

Address: ________ Name

______________________ Registration No._

Place : _Signature: _____________________________

Date : _Name of Scrutinizer :____________________